Access, demand, and utilization of childhood immunization services: A cross-sectional household survey in Western Area Urban district, Sierra Leone, 2019

Coping mechanisms and strategies adopted to improve the quality and timeliness of immunization data among lower-level private-for-profit service providers in Kampala Capital City, Uganda

BACKGROUND

Lower-level urban private-for-profit health service providers are actively engaged in the delivery of immunization services. However, not much is known about their everyday endeavours to improve data quality and ensure the submitted data meets the quality and timeliness requirements as per established guidelines. The objective of this paper was to examine the coping mechanisms and strategies adopted to improve the quality and timeliness of immunization data among lower-level private-for-profit service providers in Kampala Capital City, Uganda.

METHODS

A qualitative study design was adopted with in-depth interviews (n = 17) and key informant interviews (n = 8) completed among frontline health workers, district health managers and immunization implementing partners. Analysis followed a thematic approach with coding conducted using Atlas. ti, a qualitative data management software.

RESULTS

Overall, coping mechanisms and strategies adopted to improve the data quality among lower-level urban private-for-profit immunization service providers included; Experiential attachment for practical skills acquisition in data management, data quality peer-to-peer learning among private-for-profit immunization service providers, registration using cohort system for easy tracking of records during subsequent visits, separation of visiting service user records from regular attendants, service delivery modifications such as reward for better performance, engagement of Village Health Teams (VHTs) in outreaches and data completion, and data quality checks through review of monitoring charts to identify gaps in data quality.

CONCLUSIONS

Within the urban context, the delivery of immunization services by lower-level private-for-profit services faces data quality challenges some of which stem from the implementation context. Different coping strategies focusing on frontline health worker skills, enhanced experience sharing through peer-to-peer learning, modifications to registration and routine review of monitoring charts. However, these efforts were often faced with chronic barriers such as the high staff turnover calling for dedicated efforts to optimize the available implementation opportunities like guidelines mandating the public health facilities to supervise the lower-level private immunization service providers within their catchment areas to respond to the identified gaps.

Using photovoice methodology to uncover individual-level, health systems, and contextual barriers to uptake of second dose of measles containing vaccine in Western Area Urban, Sierra Leone, 2020

Background

Vaccination coverage for the second dose of the measles-containing vaccine (MCV2) among children has remained stagnant in Sierra Leone at nearly 67% since its introduction in 2015. Identifying community-specific barriers faced by caregivers in accessing MCV2 services for their children and by health workers in delivering MCV2 is key to informing strategies to improve vaccination coverage.

Methods

We used Photovoice, a participatory method using photographs and narratives to understand community barriers to MCV2 uptake from March- September 2020. Six female and five male caregivers of MCV2-eligible children (15-24 months of age), and six health care workers (HCWs) in Freetown, Sierra Leone participated. After having an orientation to photovoice, they photographed barriers related to general immunization and MCV2 uptake in their community. This was followed by facilitated discussions where participants elaborated on the barriers captured in the photos. Transcripts from the six immunization-related discussions were analyzed to deduce themes through open-ended coding. A photo exhibition was held for participants to discuss the barriers and suggested solutions with decision-makers, such as the ministry of health.

Results

We identified and categorized nine themes into three groups: 1) individual or caregiver level barriers (e.g., caregivers' lack of knowledge on MCV2, concerns about vaccine side effects, and gender-related barriers); 2) health system barriers, such as HCWs' focus on children below one year and usage of old child health cards; and 3) contextual barriers, such as poverty, poor infrastructure, and the COVID-19 pandemic. Participants suggested the decision-makers to enhance community engagement with caregivers and HCW capacity including, increasing accountability of their work using performance-based approaches, among different strategies to improve MCV2 uptake.

Conclusion

Photovoice can provide nuanced understanding of community issues affecting MCV2. As a methodology, it should be integrated in broader intervention planning activities to facilitate the translation of community-suggested strategies into action.

Less than one-fifth of Ethiopian children were vaccinated for measles second dose; evidence from the Ethiopian mini demographic and health survey 2019

Ethiopia introduced the measles second dose vaccine from the routine expanded immunization program in 2018. Shreds of evidence are scarce on the measles second dose vaccination coverage and its associated factors in Ethiopia. We aimed to assess the measles second dose vaccination coverage and associated factors in Ethiopia using the recent Ethiopian Mini Demographic and Health Survey (EMDHS) 2019 data. An in-depth secondary data analysis was conducted based on the Ethiopian mini demographic and health survey 2019 data; which was a cross-sectional survey targeted on key indicators of maternal and child health. A weighted sample of 965 children was included in the analysis. A multi-level mixed effect logistics regression model was fitted. Adjusted Odds Ratio (AOR) with 95 %CI was reported for statistically significant variables. The measles second dose coverage was 12.36 % (95 %CI = 10.89, 15.44). Not vaccinated for the third dose of pentavalent vaccine (Penta 3) (AOR = 0.60, 95 %CI: 0.37, 0.95), age of the child [13 to 23 months (AOR = 2.14, 95 %CI: 1.05, 4.36), 24 to 36 months (AOR = 2.58, 95 %CI: 1.32, 5.05)], household head educational status [no education (AOR = 0.51,95 %CI: 0.26, 0.99), primary (AOR = 0.44, 95 %CI: 0.23, 0.85)], and living in south nation, nationalities and peoples region (SNNPR) (AOR = 2.83,95 %CI: 1.12, 7.11) were significantly associated with measles second dose vaccination coverage. Measles second dose vaccination coverage was low in Ethiopia. Age of the child, being vaccinated for the Penta 3, educational status of the household head, and region of residence were significant determinants of measles second dose vaccination coverage.

Qualitative assessment of caregiver experiences when navigating childhood immunisation in urban communities in Sierra Leone

OBJECTIVE

To gain in-depth understanding of the caregiver experience when navigating urban immunisation services for their children.

DESIGN

An exploratory qualitative assessment comprising 16 in-depth interviews using an interpretative phenomenology approach.

SETTING

Caregivers were purposively recruited from slums (n=8) and other urban communities (n=8) in the capital city of Sierra Leone.

PARTICIPANTS

Caregivers of children ages 6-36 months old who were fully vaccinated (n=8) or undervaccinated (n=8).

RESULTS

Emotional enablers of vaccination were evident in caregivers' sense of parental obligation to their children while also anticipating reciprocal benefits in children's ability to take care of their parents later in life. Practical enablers were found in the diversity of immunisation reminders, information access, information trust, getting fathers more involved, positive experiences with health workers and postvaccination information sharing in the community. Underlying barriers to childhood vaccination were due to practical constraints such as overcrowding and long waiting times at the clinic, feeling disrespected by health workers, expecting to give money to health workers for free services and fear of serious vaccine side effects. To improve vaccination outcomes, caregivers desired more convenient and positive clinic experiences and deeper community engagement.

CONCLUSIONS

Health system interventions, community engagement and vaccination outreach need to be tailored for urban settings. Vaccine communication efforts may resonate more strongly with caregivers when vaccination is framed both around parental responsibilities to do the right thing for the child and the future benefits to the parent.

Association of community engagement with vaccination confidence and uptake: A cross-sectional survey in Sierra Leone, 2019

Background

The 2014-2016 Ebola epidemic disrupted childhood immunization in Sierra Leone, Liberia, and Guinea. After the epidemic, the Government of Sierra Leone prioritized community engagement to increase vaccination confidence and uptake. To support these efforts, we examined potential drivers of vaccination confidence and uptake in Sierra Leone.

Methods

We conducted a population-based household survey with primary caregivers of children in a birth cohort of 12 to 23 months in four districts with low vaccination coverage in Sierra Leone in 2019. Modified Poisson regression modeling with robust variance estimation was used to examine if perceived community engagement in planning the immunization program in the community was associated with vaccination confidence and having a fully vaccinated child.

Results

The sample comprised 621 age-eligible children and their caregivers (91% response rate). Half of the caregivers (52%) reported that it usually takes too long to get to the vaccination site, and 36% perceived that health workers expect money for vaccination services that are supposed to be given at no charge. When mothers were the decision-makers of the children's vaccination, 80% of the children were fully vaccinated versus 69% when fathers were the decision-makers and 56% when other relatives were the decision-makers. Caregivers with high confidence in vaccination were more likely to have fully vaccinated children compared to caregivers with low confidence (78% versus 53%). For example, caregivers who thought vaccines are 'very much' safe were more likely to have fully vaccinated children than those who thought vaccines are 'somewhat' safe (76% versus 48%). Overall, 53% of caregivers perceived high level of community engagement, 41% perceived medium level of engagement, and 6% perceived low level of engagement. Perceiving high community engagement was associated with expressing high vaccination confidence (adjusted prevalence ratio (aPR) = 2.60; 95% confidence interval (CI) = 1.67-4.04) and having a fully vaccinated child (aPR = 1.67; 95% CI = 1.18-2.38).

Conclusions

In these four low coverage districts in Sierra Leone, the perceived level of community engagement was strongly associated with vaccination confidence among caregivers and vaccination uptake among children. We have provided exploratory cross-sectional evidence to inform future longitudinal assessments to further investigate the potential causal effect of community engagement on vaccination confidence and uptake.

Community Health Workers' Experiences in Strengthening the Uptake of Childhood Immunization and Malaria Prevention Services in Urban Sierra Leone

Introduction: Community health workers (CHWs) play an integral role in Sierra Leone's health systems strengthening efforts. Our goal was to understand CHWs' experiences of providing immunization and malaria prevention services in urban settings and explore opportunities to optimize their contributions to these services. Methods: In 2018, we conducted an exploratory qualitative assessment in the Western Area Urban district, which covers most of the capital city of Freetown. We purposively selected diverse health facilities (i.e., type, ownership, setting) and recruited CHWs through their supervisors. We conducted eight focus group discussions (FGD) with CHWs, which were audio-recorded. The topics explored included participants' background, responsibilities and priorities of urban CHWs, sources of motivation at work, barriers to CHWs' immunization and malaria prevention activities, and strategies used to address these barriers. The local research team transcribed and translated FGDs into English; then we used qualitative content analysis to identify themes. Results: Four themes emerged from the qualitative content analysis: (1) pride, compassion, recognition, and personal benefits are important motivating factors to keep working as CHWs; (2) diverse health responsibilities and competing priorities result in overburdening of CHWs; (3) health system- and community-level barriers negatively affect CHWs' activities and motivation; (4) CHWs use context-specific strategies to address challenges in their work but require further support. Conclusion: Focused support for CHWs is needed to optimize their contributions to immunization and malaria prevention activities. Such interventions should be coupled with systems-level efforts to address the structural barriers that negatively affect CHWs' overall work and motivation, such as the shortage of work supplies and the lack of promised financial support.

Evaluation of health system readiness and coverage of intermittent preventive treatment of malaria in infants (IPTi) in Kambia district to inform national scale-up in Sierra Leone

BACKGROUND

Intermittent preventive treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a proven strategy to protect infants against malaria. Sierra Leone is the first country to implement IPTi nationwide. IPTi implementation was evaluated in Kambia, one of two initial pilot districts, to assess quality and coverage of IPTi services.

METHODS

This mixed-methods evaluation had two phases, conducted 3 (phase 1) and 15-17 months (phase 2) after IPTi implementation. Methods included: assessments of 18 health facilities (HF), including register data abstraction (phases 1 and 2); a knowledge, attitudes and practices survey with 20 health workers (HWs) in phase 1; second-generation sequencing of SP resistance markers (pre-IPTi and phase 2); and a cluster-sample household survey among caregivers of children aged 3-15 months (phase 2). IPTi and vaccination coverage from the household survey were calculated from child health cards and maternal recall and weighted for the complex sampling design. Interrupted time series analysis using a Poisson regression model was used to assess changes in malaria cases at HF before and after IPTi implementation.

RESULTS

Most HWs (19/20) interviewed had been trained on IPTi; 16/19 reported feeling well prepared to administer it. Nearly all HFs (17/18 in phase 1; 18/18 in phase 2) had SP for IPTi in stock. The proportion of parasite alleles with dhps K540E mutations increased but remained below the 50% WHO-recommended threshold for IPTi (4.1% pre-IPTi [95%CI 2-7%]; 11% post-IPTi [95%CI 8-15%], p < 0.01). From the household survey, 299/459 (67.4%) children ≥ 10 weeks old received the first dose of IPTi (versus 80.4% for second pentavalent vaccine, given simultaneously); 274/444 (62.5%) children ≥ 14 weeks old received the second IPTi dose (versus 65.4% for third pentavalent vaccine); and 83/217 (36.4%) children ≥ 9 months old received the third IPTi dose (versus 52.2% for first measles vaccine dose). HF register data indicated no change in confirmed malaria cases among infants after IPTi implementation.

CONCLUSIONS

Kambia district was able to scale up IPTi swiftly and provide necessary health systems support. The gaps between IPTi and childhood vaccine coverage need to be further investigated and addressed to optimize the success of the national IPTi programme.